Date:
Patient:
MRN:
Clinician: (Sports Medicine Physician, Physical Therapist)
Reason for Visit:
Follow-up for hamstring injury
Evaluation of pain, swelling, and functional limitations
Review of imaging results (if applicable)
Discussion of treatment plan and rehabilitation progress
History of Present Illness:
Briefly describe the mechanism of injury (sudden onset during activity, gradual increase in pain)
Location and severity of pain (sharp, dull, aching)
Onset, duration, and progression of symptoms
Functional limitations (walking, running, stairs)
Past Medical History:
Previous hamstring injuries
Underlying medical conditions relevant to healing (vascular disease, diabetes)
Physical Exam:
Gait assessment: Look for any limping or altered gait mechanics.
Range of motion: Assess hip and knee flexion for limitations.
Palpation: Evaluate for tenderness, swelling, and muscle tone in the hamstring muscles.
Strength testing: Assess the strength of the hamstring muscles compared to the uninvolved side.
Special tests (e.g., straight leg raise test) may be performed to assess specific muscle involvement.
Imaging:
Ultrasound: Often the first-line imaging study to identify muscle tears, hematomas (blood clots), and assess inflammation.
MRI scan: May be used in some cases for a more detailed evaluation, especially if a complete tear is suspected.
Assessment:
Summarize the diagnosis and severity of the injury:
Grade the hamstring strain based on severity (grade 1 – mild strain, grade 2 – partial tear, grade 3 – complete tear).
Identify any associated injuries (knee, lower back).
Plan:
Outline the treatment plan based on the severity of the injury:
Acute phase (first 1-3 days):
PRICE therapy (Protection, Rest, Ice, Compression, Elevation)
Pain medication (anti-inflammatory drugs)
Rehabilitation phase:
Physical therapy to promote healing, restore strength, flexibility, and balance.
Gradual return to activity program based on progress.
Consider mentioning the importance of patient education regarding proper use of crutches or assistive devices if needed.
Prognosis:
Briefly discuss the expected healing time based on the severity of the injury:
Grade 1 strains: Healing typically within 1-2 weeks.
Grade 2 strains: Recovery time of 4-8 weeks.
Grade 3 strains: May require surgical repair and rehabilitation for several months.
Education:
Document any education provided to the patient regarding:
The nature of the hamstring injury and its severity (grade)
The importance of adhering to the treatment plan, including rest and physical therapy exercises
Pain management strategies (ice, pain medication)
Warning signs and symptoms of complications (worsening pain, swelling, fever)
Gradual return to activity guidelines and safe exercise techniques to prevent reinjury
Notes:
Include any additional relevant information not covered above, such as the patient’s understanding of the diagnosis and treatment plan, and any concerns they may have about pain management, recovery time, or returning to their desired level of activity.
Disclaimer: This is a template and should be adapted to the specific needs of each patient. It is important to consult with a sports medicine physician or physical therapist for diagnosis, treatment recommendations, and prognosis.